More privacy and less visibility at Perth Children’s Hospital have taken some getting used to by nurses, patients and their families, according to Associate Professor Fenella Gill.
The design and functionality of workplaces are critical to ensuring employees can complete their jobs to their best ability. Hospitals play a key role in our health system, and it is vital that their design meets the needs of staff, patients and their families.
The Perth Children’s Hospital opened in May 2018 – a state-of-the-art hospital providing world-class medical care to WA children in need, and a home to their families who are supporting them.
Any shift into a new work environment can have its challenges, and our team aimed to identify any impacts of the new working environment on PCH stakeholders.
Our research, published in the Journal of Health Services Research & Policy, found that increased privacy for patients and families at the expense of decreased visibility has emerged as the dichotomy of design at PCH.
We were also able to show the design had many positive outcomes including privacy and natural light, but initially challenges reported by nurses working in ward areas were that they experienced feeling exhausted, isolated, and less visible to patients and their families.
At the time of planning this study, the influence of building design with single rooms on patient, family and nurse experience and workflow in a children’s hospital was unquantified, although anticipated challenges were that single patient rooms could increase nurse workload while simultaneously reducing nurse-time spent with patients.
We looked to address the knowledge gap by measuring the effects from a nursing, patient, and family point of view.
The design strategies evaluated included the predominance of single patient rooms with ensuite bathrooms (from 26% at Princess Margaret Hospital to 75% at PCH) and a 65% larger floor space in ward areas.
To optimise nurse-time with patients, design features included V-shaped wards and decentralised nurses’ stations to increase visibility, as well as automated medication dispensing machines to promote efficient medication management and digital hands-free communication technology to facilitate communication between staff.
PCH architectural features maximised natural light, quietness, and views of nature.
Our research revealed both benefits and challenges. Patients and families liked the new environment, especially how families could all be together in the patient room, yet also recognised how the design resulted in reduced visibility of nurses and a sense of isolation.
After collecting data on the movements of registered nurses, we found they spent the same amount of time at patients’ bedsides, yet they spent double the amount of time walking in the new hospital from an estimated 10 minutes at PMH to about 20 minutes at PCH.
Time spent documenting significantly fell, as did time spent undertaking ward activities and indirect care activities, including supervision of others, while time communicating with other staff increased.
Out of sight
Nurses told us that the new environment resulted in them initially experiencing exhaustion; being less visible to families and other nurses; and decreased capacity to supervise less experienced nurses.
Over time they did adjust to their new working environment and their experiences improved. However, the experience of increased walking persisted, and similarly, despite the hard data of no change to nurse time spent at patients’ bedsides, the perception and experiences of children, families and nurses were that nurses were less visible and spent less time with patients.
Through surveys we collected, nurses reported a decrease in their perceptions of staffing and resource adequacy and in focus groups nurses told us they felt as if there was an insufficient number of nurses.
We identified four key themes that provided further explanation for the perceived decrease in nurse staffing and resource adequacy. These were:
- adapting to ward design and managing workflow in the different environment
- nurse experience of reduced visibility interlinked with how nurses viewed their capacity to take responsibility for patients and provide care, and;
- technology communication.
Reduced visibility of patients has been previously linked to nurses perceiving there are inadequate resources and experiencing a lack of control over their practice.
The nursing gaze framework describes the process by which nurses assess patient needs against a background of what they consider to be normal in the context of the patient’s condition and the work environment. This gaze guides the setting of work priorities and supporting others.
The challenge of supervising other nurses in single room environments has also been previously reported and includes concern over loss of surveillance of patients.
Despite these initial concerns, a year after moving to PCH, many nurses preferred single rooms, saying they thought that patients and families were happier, noting that “It takes a little bit of work, but you do adjust to the actual working environment … we support each other a little bit more.”
Once they became familiar with using the technology, nurses especially valued the digital hands-free communication technology for working with reduced visibility.
Individual survey item responses confirmed families’ preferences for the space, privacy, and quiet of single rooms but families also observed at PCH that nurses appeared to be working in a more pressured environment and were less visible to them.
“… you look and there’s often not anyone visible,” one parent commented. “But for some reason that never seemed to happen at the old hospital, the people always seemed to be on the ward.” Yet overall, the experience of care reported by families increased after the move while children’s experiences were unchanged.
The complexities we have identified can be used to assist new hospital design planners to consider potential impacts on nurse, patient and family experience as well as nurse workflow.
ED: The author acknowledges the help of research participants and Channel 7 Telethon Trust for funding the study. A/Prof Fenella Gill holds roles with Curtin University and Perth Children’s Hospital.